Psychosis is a mental health condition characterized by a disconnection from reality that affects how a person perceives, processes, and responds to their environment. Psychosis is an amalgamation of psychological symptoms resulting in a loss of contact with reality. While historically used to describe any mental health condition interfering with normal functioning, psychosis is now understood as a specific set of symptoms that can occur in various contexts, affecting 1.5 to 3.5% of people who will meet diagnostic criteria for a psychotic disorder, with a significantly larger, variable number experiencing at least one psychotic symptom in their lifetime.
Understanding psychosis is crucial for individuals experiencing these symptoms and their families, as early recognition and treatment can significantly improve outcomes. With early diagnosis and appropriate treatment, it is possible to recover from psychosis. Some people who receive early treatment never have another psychotic episode. For other people, recovery means the ability to lead a fulfilling and productive life, even if psychotic symptoms sometimes return.
Table of Contents
- What Is Psychosis?
- Types and Causes of Psychosis
- Symptoms of Psychosis
- Prevalence and Statistics
- Treatment for Psychosis
- Postpartum Psychosis
- Psychotic Depression
- Frequently Asked Questions
- How Therapy Can Help
What Is Psychosis?
Psychosis is a state of mind involving significant disruptions in thinking, perception, emotions, and behavior that result in a loss of contact with reality. Psychosis is an amalgamation of psychological symptoms resulting in a loss of contact with reality. The current thinking is that although around 1.5 to 3.5% of people will meet diagnostic criteria for a psychotic disorder, a significantly larger, variable number will experience at least one psychotic symptom in their lifetime. Psychosis is a common feature of many psychiatric, neuropsychiatric, neurologic, neurodevelopmental, and medical conditions. It is the hallmark feature of schizophrenia spectrum and other psychotic disorders, a co-occurring aspect of many mood and substance use disorders, as well as a challenging symptom of many neurologic and medical conditions. Psychosis can result in high levels of distress for patients and loved ones, which is why it has become a primary target of treatment for medical professionals.
The primary signs of psychosis include:
- Hallucinations: Sensory experiences of things that aren't real, including:
- Auditory (hearing voices or sounds)
- Visual (seeing things that aren't there)
- Tactile (feeling sensations without physical cause)
- Olfactory (smelling odors that don't exist)
- Gustatory (tasting things without a source)
- Delusions: Fixed false beliefs that persist despite contradictory evidence, such as:
- Persecutory delusions (believing someone or something is out to get them)
- Referential delusions (beliefs that things in the external environment are directed at them)
- Grandiose delusions (beliefs of exceptional abilities or importance)
- Somatic delusions (false beliefs about body functioning)
Types and Causes of Psychosis
Psychosis is not a standalone condition but rather appears as a symptom of various underlying conditions. Some conditions that commonly feature psychosis include:
Primary Psychotic Disorders
- Schizophrenia: The most commonly associated condition with psychosis
- Schizoaffective disorder: Combining symptoms of schizophrenia and mood disorders
- Schizophreniform disorder: Similar to schizophrenia but lasting less than six months
- Brief psychotic disorder: Sudden onset lasting between one day and one month
- Delusional disorder: Presence of delusions without other significant psychotic symptoms
Other Mental Health Conditions
- Bipolar disorder: Psychotic symptoms can occur during severe manic or depressive episodes
- Major depression with psychotic features: Severe depression accompanied by hallucinations or delusions
- Post-traumatic stress disorder (PTSD): Can occasionally include psychotic symptoms
Medical and Neurological Causes
Psychosis may be a symptom of a mental illness, such as schizophrenia, bipolar disorder, or severe depression. Additionally, medical conditions including:
- Parkinson's disease
- Alzheimer's disease
- Brain tumors
- Epilepsy
- HIV/AIDS (in advanced stages)
- Severe infections affecting the brain
Substance-Related Causes
- Cannabis use (particularly high-potency varieties)
- Stimulants (methamphetamine, cocaine)
- Hallucinogens
- Alcohol withdrawal
- Certain prescription medications
Risk Factors
There is no one cause of psychosis. Psychosis appears to result from a complex combination of genetic risk, differences in brain development, and exposure to stressors or trauma. Research has identified several factors that may increase risk:
- Family history of psychotic disorders
- Prenatal exposure to infections or malnutrition
- Childhood trauma or adverse experiences
- Social isolation
- Urban environment during childhood
- Migration and minority status
- Cannabis use, especially during adolescence
Symptoms of Psychosis
The symptoms of psychosis can vary widely between individuals and may change over time. People are usually first diagnosed with schizophrenia between the ages of 16 and 30, after the first episode of psychosis. Research shows that gradual changes in thinking, mood, and social functioning often appear before the first episode of psychosis. Identifying these subtle changes and connecting people with treatment before their first episode could have long-term benefits for their health, well-being, and daily functioning.
Core Symptoms
Beyond hallucinations and delusions, psychosis symptoms include:
- Disorganized thinking: Difficulty organizing thoughts or connecting them logically
- Disorganized or abnormal motor behavior: Unpredictable or inappropriate actions, catatonia
- Negative symptoms: Reduced emotional expression, motivation, or social engagement
Associated Symptoms
People experiencing psychosis may also show:
- Extreme emotions, particularly aggression or profound sadness
- Incoherent or disorganized speech
- Social withdrawal or isolation
- Sleep disturbances (too much or too little)
- Difficulty with self-care
- Anxiety and depression
- Cognitive difficulties (problems with memory, attention, or decision-making)
Early Warning Signs
Research strongly supports the first few years after the start of psychotic symptoms as a critical period for intervention because this is when the steepest decline in health usually occurs, and the greatest therapeutic response can be achieved. Early warning signs may include:
- Gradual social withdrawal
- Decline in school or work performance
- Difficulty concentrating
- Increased suspiciousness
- Unusual thoughts or beliefs
- Changes in perception (colors seeming brighter, sounds seeming louder)
- Feeling disconnected from others
- Decline in personal hygiene
Prevalence and Statistics
Understanding the scope of psychosis helps contextualize its impact on individuals and society:
General Population Statistics
- Approximately 3 out of 100 people living in the U.S. have or will experience a psychotic episode in their lives.
- The global number of new schizophrenia cases increased from 883,493 in 1990 to 1,223,221 in 2021, showing a significant increase in absolute numbers. However, the age-standardized incidence rate showed an overall downward trend, with an annual decline of 0.04%.
- Every year, about 100,000 teenagers and young adults in the United States experience their first psychotic episode.
Age and Gender Patterns
- The primary psychotic disorder will usually present in the late teens to the early thirties. Men typically present with the condition earlier than women.
- Males have higher age-standardized incidence and prevalence rates than females.
Specific Disorder Prevalence
- Schizophrenia led to an excess economic burden of $343.2 billion in the U.S.
- Less than 1% of the U.S. population lives with a psychotic disorder.
- Estimated share of people who had schizophrenia in the past year, whether or not they were diagnosed, based on representative surveys, medical data and statistical modeling.
Global Burden
- Incidence, prevalence, and global burden of schizophrenia—data, with critical appraisal, from the Global Burden of Disease (GBD) 2019. Molecular Psychiatry, 28, 5319–5327.
- Despite the wide variation in the methodological components of the studies reviewed, these data indicate that approximately one in 150 individuals will be diagnosed with psychosis disorders at some point during their lifetime.
Treatment for Psychosis
Early intervention and comprehensive treatment are crucial for managing psychosis effectively. The World Health Organization recommends a delay of no more than 90 days between the start of psychosis symptoms and specialized treatment. Simply put, early intervention is critical.
Coordinated Specialty Care (CSC)
The gold standard for treating first-episode psychosis is Coordinated Specialty Care (CSC), a team-based approach that has transformed treatment outcomes. NIMH initiated the Recovery After an Initial Schizophrenia Episode (RAISE) research initiative to investigate a new way of treating early psychosis called coordinated specialty care (CSC). Results showed that CSC can reduce the burden of first-episode psychosis and improve the lives of people with schizophrenia. CSC is a research-to-practice victory that charts the journey of schizophrenia treatment from dire beginnings to action-oriented research to broad implementation in the U.S. health care system. RAISE inspired a revolution in treating schizophrenia, leading to the rapid growth of CSC programs nationwide and increased access to high-quality care for thousands of Americans.
CSC components include:
- Case management: Coordinating all aspects of care
- Psychotherapy: Individual and group therapy sessions
- Medication management: Careful prescribing at the lowest effective doses
- Family education and support: Helping families understand and cope
- Supported education and employment: Assistance returning to school or work
- Peer support: Connection with others who have similar experiences
Expansion of CSC Programs
In 2014, Congress designated $25 million to the Substance Abuse and Mental Health Services Administration (SAMHSA)'s Community Mental Health Block Grant program. The program supports evidence-based treatments that address the needs of people with early serious mental illnesses, including psychotic disorders. The set-aside funding doubled to $50 million in 2016 and has increased every year since, resulting in a total investment in early psychosis care of nearly $430 million as of 2021. Federal investment in CSC has had a significant impact. In 2020, SAMHSA reported to Congress that 340 CSC programs for first-episode psychosis operated in all 50 states—a 30-fold increase in early psychosis programs compared to the years before RAISE.
Medication Treatment
Antipsychotic medications are often a key component of psychosis treatment:
- Second-generation antipsychotics: Generally preferred due to fewer movement-related side effects
- Dosing strategies: Starting with the lowest effective dose and adjusting based on response
- Monitoring: Regular assessment of effectiveness and side effects
- Long-acting injectable formulations: Available for those who struggle with daily medication adherence
Psychotherapy Approaches
Cognitive Behavioral Therapy for Prodromal Stage of Psychosis—Outcomes for Transition, Functioning, Distress, and Quality of Life: A Systematic Review and Meta-analysis Schizophrenia Bulletin. This study aimed to provide insight into the efficacy of CBTp in patients with CHR-P.
Effective psychotherapy approaches include:
- Cognitive Behavioral Therapy for Psychosis (CBTp): Helps individuals understand and manage symptoms
- Family therapy: Improves communication and reduces stress within families
- Cognitive remediation: Targets cognitive difficulties
- Social skills training: Helps rebuild social connections
- Metacognitive training: Addresses thinking biases associated with psychosis
Recovery and Outcomes
The Recovery After an Initial Schizophrenia Episode (RAISE) research project, supported by NIMH, established coordinated specialty care as an effective treatment for early psychosis and identified important elements for helping people lead productive, independent lives. Learn more about the RAISE studies. NIMH continues to prioritize research on and expansion of treatments for early psychosis with the launch of the Early Psychosis Intervention Network (EPINET) in 2019. Through EPINET, NIMH funded awards to establish a national data coordinating center and regional scientific hubs connected to more than 100 coordinated specialty care programs that provide early psychosis treatment in 17 states.
Recovery rates vary, but with appropriate treatment:
- Many individuals return to school or work
- Social relationships can be rebuilt and maintained
- Quality of life significantly improves
- Some people experience complete remission of symptoms
Barriers to Treatment
Despite effective treatments, barriers remain:
- Limited availability of specialized programs in some areas
- Stigma preventing help-seeking
- Lack of awareness about early warning signs
- Insurance coverage limitations
- Cultural and linguistic barriers
Postpartum Psychosis
Postpartum psychosis is a rare but serious mental health emergency that can occur after childbirth. Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. Although rare, it is considered a psychiatric emergency that warrants immediate medical attention and inpatient care to ensure safety, complete diagnostic evaluation, and treatment initiation. This article describes the phenomenology of postpartum psychosis, clinical evaluation, treatment guidelines, and prevention strategies.
Prevalence and Timing
- The most frequently reported incidence of postpartum psychosis is 0.89 to 2.6 in 1,000 births.
- With an estimated global prevalence of 0.089 to 2.6 per 1000 births, postpartum psychosis classifies as an illness with a low incidence rate.
- Episodes of postpartum psychosis tend to cluster in the first few weeks after delivery; however, women remain at risk of having severe mood and psychotic episodes for several months.
Risk Factors
Risk factors include a history of bipolar disorder, history of postpartum psychosis in a previous pregnancy, family history of psychosis or bipolar disorder, history of schizoaffective disorder or schizophrenia, and discontinuation of psychiatric medications during pregnancy. The overall prevalence is higher in patients suffering from affective disorders like bipolar one, two, and first-time pregnancy with a previous family or personal history of bipolar one disorder is considered the single most important risk factor.
Additional risk factors include:
- Sleep deprivation during the perinatal period
- Hormonal changes after delivery
- First pregnancy
- Pregnancy complications or traumatic delivery
- Lack of social support
Symptoms and Presentation
Postpartum psychosis is the severest form of mental illness in that category characterized by extreme confusion, loss of touch with reality, paranoia, delusions, disorganized thought process, and hallucinations.
Symptoms typically include:
- Severe mood swings (elation to deep depression)
- Confusion and disorientation
- Hallucinations (often involving the baby)
- Delusions (frequently about the baby's identity or safety)
- Paranoia
- Attempts to harm self or baby
- Severe insomnia
- Hyperactivity or agitation
Treatment Approaches
ECT is effective for rapid clinical improvement in mania, severe depression, catatonia, and psychotic disorder, and for treatment resistance of these conditions outside of the postpartum time period. Data regarding the use of ECT in the postpartum period are limited to case series and population studies that have limited sample sizes due to the low prevalence of postpartum psychosis. Retrospective studies of women who are treated for postpartum psychosis or postpartum affective disorders demonstrate excellent response and remission rates. ECT has also been used as a first-line treatment. A Swedish population study suggested that the response rate to ECT for depression and psychosis is higher in the postpartum period than outside the postpartum period, with remission rates of 87% (in the postpartum group) compared with 73.5% (in the matched nonpostpartum group).
Treatment typically involves:
- Immediate hospitalization: Often in a specialized mother-baby unit
- Medication: Antipsychotics, mood stabilizers, or antidepressants
- Electroconvulsive therapy (ECT): For severe cases or when rapid response is needed
- Psychotherapy: Once acute symptoms stabilize
- Family support and education: Critical for recovery
Outcomes and Prognosis
If not identified and treated, individuals diagnosed as having postpartum psychosis are at an elevated risk for suicide and infanticide. Early identification and treatment of this condition is key to minimizing these risks and preventing negative consequences for the mother and baby.
With prompt treatment:
- Most women recover fully
- Risk of recurrence in future pregnancies is approximately 30-50%
- Long-term outcomes are generally good with appropriate follow-up
- Many women have no further episodes outside the postpartum period
Psychotic Depression
Psychotic depression, also known as major depression with psychotic features, represents a severe form of depression accompanied by psychotic symptoms. Around 14% of people with severe depression had a history of psychotic features.
Characteristics
Psychotic depression differs from other forms of depression by the presence of:
- Mood-congruent delusions: False beliefs consistent with depressive themes (worthlessness, guilt, disease, death)
- Hallucinations: Often auditory, with content related to depressive themes
- Severe functional impairment: Greater than in depression without psychotic features
- Higher suicide risk: Due to the combination of severe depression and impaired reality testing
Treatment Considerations
Treatment typically requires:
- Combination therapy: Both antidepressants and antipsychotics
- Hospitalization: Often necessary due to severity and suicide risk
- ECT: Particularly effective for psychotic depression
- Close monitoring: Due to elevated risk of self-harm
- Longer treatment duration: Compared to non-psychotic depression
Frequently Asked Questions
What is the difference between psychosis and schizophrenia?
Psychosis is a common feature of many psychiatric, neuropsychiatric, neurologic, neurodevelopmental, and medical conditions. It is the hallmark feature of schizophrenia spectrum and other psychotic disorders, a co-occurring aspect of many mood and substance use disorders, as well as a challenging symptom of many neurologic and medical conditions. The key distinction is that psychosis is a symptom that can occur in many conditions, while schizophrenia is a specific diagnosable mental health disorder that includes psychosis along with other symptoms.
Can people recover from psychosis?
Yes, recovery is possible. With early diagnosis and appropriate treatment, it is possible to recover from psychosis. Some people who receive early treatment never have another psychotic episode. For other people, recovery means the ability to lead a fulfilling and productive life, even if psychotic symptoms sometimes return.
How quickly should someone seek treatment for psychosis?
The World Health Organization recommends a delay of no more than 90 days between the start of psychosis symptoms and specialized treatment. Simply put, early intervention is critical. The sooner treatment begins, the better the outcomes tend to be.
What should family members do if they suspect a loved one is experiencing psychosis?
Family members should:
- Stay calm and non-judgmental
- Encourage the person to seek professional help
- Contact a mental health crisis line if immediate help is needed
- Learn about psychosis and available treatments
- Consider family education programs offered by treatment providers
Are there ways to prevent psychosis?
While not all cases can be prevented, risk can be reduced by:
- Avoiding cannabis and other drugs, especially during adolescence
- Managing stress effectively
- Getting adequate sleep
- Seeking help for mental health concerns early
- Participating in early intervention programs if at high risk
What is the clinical high-risk state for psychosis?
The construct of Clinical-High Risk for Psychosis (CHR-P) identifies young help-seeking subjects in putative prodromal stages of psychosis and is a central component of the Early Intervention (EI) paradigm in Mental Health, aimed at facilitating rapid entry into appropriate care pathways to prevent the onset of psychosis or mitigate its biopsychosocial consequences. This approach, which promotes an innovative culture of care for early, at-risk situations, is inspired by a clinical staging concept as a guide to optimal treatment.
How Therapy Can Help
Seeking help from a qualified mental health professional is essential for anyone experiencing symptoms of psychosis. Therapy provides a safe, supportive environment to:
- Understand and manage symptoms
- Develop coping strategies
- Process the experience of psychosis
- Rebuild confidence and self-esteem
- Work toward personal goals
- Strengthen relationships
- Plan for the future
Finding the Right Treatment
It is important to find a mental health professional who is trained in psychosis treatment and who makes the person feel comfortable. When looking for treatment:
- Seek providers with experience in psychosis or early intervention
- Ask about evidence-based approaches like CBT for psychosis
- Inquire about coordinated specialty care programs in your area
- Consider cultural and linguistic needs
- Verify insurance coverage and payment options
Resources for Treatment
Several organizations can help locate appropriate treatment:
- Early Psychosis Intervention Network (EPINET): EPINET's Early Psychosis Intervention Network Clinics provide treatment and services to individuals with early psychosis across 17 states. National Alliance on Mental Illness (NAMI): The NAMI HelpLine can connect you with the NAMI office in your state and help you find programs close to your location
- SAMHSA's National Helpline: 1-800-662-4357
- Local community mental health centers
- University medical centers with specialized psychosis programs
Remember, for acute onset psychosis in patients ultimately developing a schizophrenia-spectrum psychotic disorder, early intervention may improve clinical outcomes. Delays in treatment have statistical links with poorer treatment outcomes. Don't hesitate to reach out for help—effective treatment is available, and recovery is possible.
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